We stepped in to host West Coast showings of the teleconference when it was learned it would not otherwise be available, and hosted showings in Bellevue, WA, San Jose, and Anaheim, CA. More than 250 people were in attendance at these locations.

As presented in the teleconference, the following major changes to the survey process are to be implemented in less than one year:

• The incorporation of Quality Indicators (QIs) into the survey process, including using QIs to pre-select concerns and sample residents.
• New guidance and procedures for surveyors to assess residents over age 65 who receive certain drugs considered less than optimal for this age group as contained in the Beers list.
• New investigative protocols for unintended weight loss, hydration, pressure sores, sufficient staffing, and an enhanced dining observation protocol.
• Assessment of how the facility prevents abuse, neglect, and misappropriation of property.

Our Resident Assessment Product Manager attended HCFA training in mid-May and provides this interpretation and overview.

This listing of changes and additions to the survey process is not complete and it is subject to change by HCFA. HCFA is always the final authority.

Survey Tasks

Offsite survey preparation
Surveyors are directed to identify and pre-select concerns (and residents) based on three Quality Indicator Reports:

• Facility Report–provides demographic information about the resident population (in percentages) compared to all facilities in the state.
• QI Profile–provides facility status for each QI as compared to a peer group of the facilities in the state.
• Resident Level Summary–provides resident-specific QI information.

• Any Sentinel Event that is flagged.
• Any other QI in which the facility is at the 75th percentile or greater.

A Sentinel Event is a QI that represents a significant occurrence that should be investigated. The Sentinel Event QIs are Prevalence of Fecal Impaction, Prevalence of Dehydration and Prevalence of Pressure Ulcers (in residents at low risk for pressure ulcers). If even one resident has any of these conditions, this QI will be flagged and the care area must be selected as a concern and the resident with the problem must be selected for the sample.

Entrance conference
When the survey team arrives, they will provide the Administrator with copies of the three QI reports and the OSCAR 3 and 4 reports.

Surveyors will ask the administrator to describe any special features of the facility’s care and treatment programs, organization, and resident case mix.

The administrator will be asked for the facility’s policies and procedures to prevent abuse and the name of a person the administrator designates to answer questions about abuse prevention.

The administrator will be asked for documents and lists, including the Roster/Sample Matrix (HCFA-802), which is to be completed first. Note: The HCFA-802 has been revised. CARE is currently updating VistaCARE Resident Assessment to reflect the changes.

The administrator will be asked to provide the Resident Census and Conditions report (HCFA-672) within 24 hours.

The administrator is to provide the current resident activity schedule/calendar and lists that include:

• Medicare residents who have requested demand bills in the past six months
• any residents age 55 and under
• any residents who communicate with devices, sign language, or do not speak the dominant language of the facility.

Initial tour
When standard tours begin beyond the hours of 8 a.m. to 6 p.m. or on a Saturday or Sunday, surveyors are directed to modify the initial tour in recognition of the residents’ activity, (e.g. sleep, religious services) and types and number of staff available.

Facility staff will be asked to identify residents who have been admitted within the past 14 days for possible inclusion in the sample. Staff will also be asked to identify residents to be transferred or discharged within the next 30 days.

Surveyors will determine if, in the pre-selected sample of residents, there are family members of non-interviewable residents who can be selected for a Quality of Life Assessment family interview.

In the initial tour, surveyors are to observe the emotional and behavioral conduct of residents, and reactions and interventions by staff. Also a focus: the nature and manner of staff interactions, response time, staff availability, and staff competence.

Surveyors are also to focus on care issues, such as, how care is provided, and the prevalence of special care needs.

Sample selection
The Phase 1 sample is preselected offsite, based on QIs and other areas of concern. The only reason to eliminate residents from the sample is if they are discharged (they may be selected for closed record reviews).

The Phase 2 sample is selected onsite, part way through the survey, to represent new concerns and/or to continue further investigation of Phase 1 concerns.

It is statutorily required that the sample in each facility be case-mix stratified in order to capture both interviewable and non-inter-viewable residents, and residents from both heavy and light-care categories.

HCFA notes that for facilities with a population of “short-stay” residents, it may not have been possible to select concerns or a resident sample offsite. In that case, Phase 1 sample selection will occur onsite.

If no residents were selected offsite for dehydration, surveyors should select at least one resident with risk factors for dehydration.

Other Phase 2 tasks
If the team has identified quality of care problems during Phase 1 of the survey, they are to use the investigative protocol for Nursing Services, Sufficient Staffing to gather information to determine compliance with the following requirement: 483.30(a), F353 Nursing services, sufficient staff and 483.30(b), F354, Registered Nurse (see SOM).

Information gathering
As one of the subtasks, surveyors are to determine whether the facility has policies and procedures to protect residents from abuse, neglect, involuntary seclusion, and misappropriation of their property. This includes policies and procedures for hiring, training and ongoing supervision for employees and volunteers, and the reporting and investigation of allegations and occurrences that may indicate abuse.

General procedures
Avoidable or Unavoidable Decline: If a surveyor verifies a resident’s condition has declined, they are directed to determine if the decline was unavoidable by asking a knowledgeable staff member to show documentation of reasons for the decline in the resident’s chart. Surveyors are directed to use this information to guide their investigation, but to use their professional judgment and team approach to determine if a deficient practice has occurred.

Resident review – comprehensive care review
After observing and talking with the resident, the surveyor conducts a comprehensive review, including:

• A check of specific items on the MDS for accurate coding at the time the MDS was completed. At least two QIs identified for the resident must be matched against the QI definitions and evidence other than the MDS.
• An overall review of the Resident Assessment Instrument (RAI) process including the facility’s use of the RAPs and development of a care plan.
• Review of the implementation of the care plan and resident response.
• Relationship of drug regimen to the resident’s condition.
• A thorough review of any of the following conditions that apply to the resident: weight loss, dehydration, pressure sores.
• An evaluation of the resident’s dining experience, using the Dining Observation Protocol (see SOM).

Assessment of drug therapies:
Surveyors are directed to evaluate for the presence of any unnecessary drugs. Their review of the medication regimen is to include: indications/reason for use, effectiveness of therapeutic goal, dose, presence of monitoring, presence of duplicative therapy, and presence of possible Adverse Drug Reactions or side effects. The SOM contains an investigative protocol for the review of apparent adverse drug reactions.

Investigative protocols
Resident reviews are to be completed using the investigative protocols found in the SOM for assessment of compliance in the areas of pressure sores, hydration, weight loss, dining, sufficient staffing, adverse drug reactions, and abuse prevention. It is important to note that a resident included in the survey for certain QI triggers, may be reviewed for additional concerns. For example, the Investigative Protocol for Hydration (see SOM) can be implemented when a sampled resident is discovered to have risk factors, including elevated temperatures, use of cardiovascular agents, renal disease, dysphagia, or lacking the sensation of thirst.